13.3.1 Nervus intermedius neuralgia

Identification: Female patient, 45 years old, with episodes of deep auricular pain for 6 months.

History of Present Illness:
Characteristics of Pain:
Location:

Deep external auditory canal (80%)
Retroauricular region (20%)

Type:

Stabbing paroxysms (1-10 seconds)

Intensity 9-10/10 (VAS)

Frequency: 10-30 episodes/day

Triggers:

Touching the tragus (3mm² trigger area)
Mandibular movements
Thermal stimulation (cold air)

Associated Symptoms:
Ipsilateral hyperacusis during episodes
Transient dysgeusia (metallic taste)

Relevant History:
Herpes zoster oticus 2 years ago (without apparent sequelae)
Ipsilateral TMJ surgery 5 years ago

Physical/Neurological Examination:
Otoneurological Assessment:

Hyperesthesia in the external acoustic meatus
Stapedius reflex preserved

Provocative Tests:

Pressure on the tragus → reproduction of typical pain

General Examination:

No motor or sensory deficits
Normal temporomandibular joint

Complementary Exams:
3T MRI (FIESTA):

Course of the intermediate nerve without vascular compression
Absence of lesions in the cerebellopontine angle

Electrophysiology:

Diagnostic block with 2% lidocaine in the auditory meatus → complete relief for 6 hours

Otological Evaluation:

Normal tympanometry
Otoacoustic emissions present